What to Expect When Girls are Expecting: Psychosocial Support Challenges and Opportunities in the Context and Aftermath of Teenage Pregnancy in Kenya

doi:10.21203/rs.3.rs-1716775/v2

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Research Article

What to Expect When Girls are Expecting: Psychosocial Support Challenges and Opportunities in the Context and Aftermath of Teenage Pregnancy in Kenya

https://doi.org/10.21203/rs.3.rs-1716775/v2

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Background

This qualitative study was conducted in Homa Bay County, Kenya, to examine teenage girls’ experience of pregnancy and parenting, and their resultant psychosocial support needs in a context in which school re-entry for girls who have experienced pregnancy is currently vigorously promoted.

Methods

The study used a descriptive phenomenological approach in analyzing counseling case notes documented by psychologists who counseled 20 pregnant or parenting girls as part of a psychosocial response integrated into a data collection process for a larger, quantitative survey. The counseling case notes were analyzed thematically.

Results

Emerging master themes were related to pregnant and parenting girls’ experience of sexual violence and adverse childbirth outcomes; psychological trauma confronted by girls and their parents alike; parental need for support in communicating with pregnant/parenting girls about sex and sexuality; and the availability of family support to help girls return to school.

Conclusions

Pregnant and parenting teenage girls require a range of psychosocial support responses that recognize the realities of sexual violence and other traumas in the lives of the girls themselves, as well as in the lives of their parents and caregivers. While parents and other caregivers can serve as an important resource for supporting affected girls who want to return to school, they often need assistance, too, in order to support pregnant/parenting girls effectively. These realities need to be taken into account if school re-entry programs for this population are to maximize their effectiveness.

Teenage pregnancy

early pregnancy

school re-entry

psychosocial support

psychosocial support for parents

adolescent mental health

Kenya

This study looked into the lives of pregnant and parenting girls in Kenya by examining case notes that were written up by psychologists during the counseling sessions they held with 20 different teenage girls who were pregnant, or already had children. The case notes provided an understanding of the kind of support pregnant and parenting girls need, including mental health care to deal with the trauma of sexual violence (and other issues) that some had experienced. It also helped put a spotlight on the traumas that parents of pregnant and parenting girls face after a teenage pregnancy happens. These issues need to be addressed in order to ensure that pregnant and parenting girls are able to be as successful as possible when they go back to school. The study also showed that girls’ parents and other relatives can be a big help in supporting them as they do return to school.

In recent times, Kenya has demonstrated progressive leadership in the East African region with regard to normalizing schooling for pregnant and parenting girls – a population that was almost invariably out-of-school previously.1 Notably, evidence of this leadership was apparent prior to the COVID-19 pandemic, which served as a wake-up call for several other countries in the region. By 2019, Kenya’s President, Uhuru Kenyatta, had already pledged to endeavor to eliminate teenage pregnancy, and increase access to education for girls at the International Conference on Population and Development (ICPD) held in Nairobi that year. In July 2020, President Uhuru Kenyatta elevated the issue of teenage pregnancy further in the national consciousness by issuing a presidential directive around the registration of all pregnant girls in the country to support their access to free maternity care (Muiruri, 2020).

These influential political statements and gestures were accompanied by action on the part of the Kenyan government: In December 2020, the Ministry of Education (MoE) released gender-neutral national guidelines for fostering the school re-entry of all out-of-school children (MoE, 2020), but with a notable section dedicated to pregnant and parenting girls. The guidelines shaped an MoE-led back-to-school campaign focused on proactively identifying pregnant and parenting girls at the household level in Homa Bay and Narok Counties in Kenya; sensitizing such girls, their families, and schools to girls’ school re-entry rights and options; and tracking the actual re-entry of girls who had expressed interest in returning to school (Gachoya et al., 2021; Odwe & Undie, 2021). This campaign built on earlier efforts to counter the stigmatization of pregnant/parenting girls’ return to school and low levels of school re-entry policy awareness in schools and communities (Undie et al., 2015a; Undie et al., 2015b; Undie & Birungi, 2016). The campaign took place at the height of the COVID-19 pandemic in Kenya, in a bid to ensure that pregnant and parenting girls returned to school in an unprecedented context that presented unique barriers to their doing so. As a result of the campaign, within a 2-month period dedicated to home visits, hundreds of pregnant and parenting girls across Homa Bay and Narok (1,035 out of 1,424 reached, amounting to 73%) either re-entered school, or were intending to do so (Odwe et al., 2021). Alongside these activities, in 2021, the MoE revived a process of drafting a national Guidance and Counseling policy, with a focus on a variety of social issues, including the needs of pregnant and parenting girls.

Without question, at the policy level in particular, Kenya has mounted a vigorous effort to address the needs of pregnant and parenting girls. Nonetheless, a growing number of recent studies serve as a reminder that these important policy-level interventions must be coupled with attention to girls’ psychosocial support needs in order to be successful and sustainable. These needs have been noted to revolve around economic support (Wainaina et al., 2021; Oulo et al., 2021), mental health concerns (Population Council, RELI, & Mannion Daniels, 2021; Sidze, 2019) and stigma (Oulo et al., 2021; Sidze, 2019; Kumar et al., 2018), for instance.

These important psychosocial support issues emerged from conventional datasets focusing on pregnant/parenting girls and other stakeholders. However, data derived from actual psychosocial support contexts are yet to inform the steadily growing body of literature. Such data have the potential to deepen our understanding of a complex issue requiring urgent solutions.

This paper draws on the voices and experiences of pregnant/parenting girls and their parents in the context of counseling sessions at the household level in Homa Bay County, Kenya. Examining affected girls’ lives in this context provides an opportunity to gain deeper insight into their worlds, and to pick up on critical psychosocial support challenges and needs that have yet to make their way into the literature.

[1] In 2014, 98% of girls who had experienced pregnancy were out of school (KNBS & ICF, 2015).

Study Context

The study took place from November to December, 2019 in Homa Bay County, Western Kenya. Three focal sub-counties served as the study sites: Homa Bay, Ndhiwa, and Rangwe. Nationally, Homa Bay County is only preceded by Narok County with regard to having the highest childbearing levels among girls ages 15–19 (KNBS & ICF, 2015). A third of girls in this age range are pregnant and/or parenting, compared to 18% of their peers, nation-wide (ibid.).

For nearly a decade, the MoE (the Homa Bay County Department of Education, and the Directorate of Policy, Partnerships, and East African Community Affairs) has collaborated with education partners to promote the school re-entry of girls who dropped out due to pregnancy. Multi-level communication interventions have been employed to achieve this. At the school level, this approach involved policy dialogues with all principals in Homa Bay County’s public secondary schools (except for boys-only and boarding schools) (Undie et al., 2015b), and with all Head Teachers of public primary schools in the 3 sub-counties previously mentioned (MoE & Population Council, 2019). Within the wider community, the policy dialogues occurred via interactive radio programs on school re-entry that aired intermittently over time, and ensured that schools and communities were sensitized to similar information about Kenya’s re-entry policies. From 2015–2016, these efforts resulted in a statistically significant increase in the proportion of out-of-school pregnant/parenting girls re-entering school – from 10–16% – in the face of powerful barriers, such as poverty and the lack of childcare (Undie et al., 2016). These endeavors further culminated in an MoE-led model that aimed to bring school re-entry dialogue even closer to community members right before the onset of COVID-19 pandemic. Referred to as ‘the 3Ts’ model – ‘Trace, Track, and Talk,’ the intervention involved working with primary school heads and village chiefs to trace pregnant and parenting girls, track them down to the household level, and talk to them along with other household members (parents, siblings) about the school re-entry policy. This program intensified when COVID-19 hit, with the MoE changing its name to the ‘the 4Ts’: ‘Trace, Track, Talk, and reTurn,’ with the final ‘T’ emphasizing the government’s commitment to visiting schools in the intervention sites to ensure that girls who expressed willingness to go back to school during the household level dialogues, actually did return (Gachoya et al., 2021; Odwe et al., 2021).

In a word, Homa Bay County is uniquely positioned as a context for learning lessons about psychosocial issues that remain or linger in the face of robust programming on school re-entry for pregnant/parenting girls.

Ethical Considerations

Several levels of ethical approval were obtained prior to conducting the overall study from which this paper’s data were derived, including from the Ethics and Research Committee of the Kenyatta National Hospital-University of Nairobi in Nairobi, Kenya, and from the New York-based Institutional Review Board of the Population Council. In addition to the consent and assent processes required when interviewing minors, the study also took into account the potential trauma that interview questions on school dropout, continuation, and re-entry could pose for pregnant and parenting girls. Three psychologists were therefore incorporated into the data collection team, and received the same training as data collectors on using the study instruments and ethical issues related to the informed consent and interviewing process. The primary role of the psychologists (who also doubled up as data collectors, when they were available to do so) was to provide first line psychosocial support (in the form of immediate counseling) to girls who asked to speak to a professional in response to a question in the survey about whether they would like to use this service. In addition to first line counseling, the psychologists were trained to provide referrals for further care to those who had received counseling. The project established a relationship in advance with the Kenya Association of Professional Counselors in the neighboring County of Kisumu to attend to any acute cases referred.

Study Design and Sample

This qualitative study used a descriptive phenomenological approach to examine girls’ experience of pregnancy and parenting, and, by extension, to explore their resultant psychosocial support needs. Phenomenology is geared toward exploring, capturing, and describing the meaning of a phenomenon, such as pregnancy and parenting as a teenager, by analyzing the ‘lived experience’ – i.e., the ‘narrative account or the story of their experience, told in their own words’ (McLean et al., 2015, p.378) – of those concerned, and the phenomena that have impacted such individuals.

The study sample was drawn from a larger, quantitative survey conducted in three sub-counties within the wider Homa Bay County, namely, Homa Bay, Ndhiwa, and Rangwe. Across these sub-counties, a total of 731 girls ages 12 to 16 (regardless of pregnancy/parenting status), 729 of the girls’ parents/household heads, and 217 head teachers were interviewed at endline on their knowledge, attitudes, and practices related to school re-entry for pregnant and parenting girls. Of the 731 girls, 7% (n = 48) had ever been pregnant. Nearly half of those who had ever been pregnant (n = 20) asked to speak further to a psychologist during or after their interviews. The 3 psychologists attached to the data collection team documented counseling case notes for all pregnant/parenting girls that asked for counseling. The study is based on the narratives contained in these 20 case notes.

Data Collection and Analysis

The psychologists on the data collection team hand-recorded their counseling case notes (a record of their management of each girl that requested counseling, along with descriptions of the counseling encounter and the context in which it occurred). Their documentation of the cases involved a two-pronged process reminiscent of fieldnote documentation: initial ‘jottings’ about the counseling encounter (in order not to forget important issues raised by the client, and to be able to follow up on them during the counseling session), followed by the expansion of the notes later in the day (Emerson et al., 1995; Sanjek, 1990). Once the case notes were fully written up, they were processed in Microsoft Word and anonymized before being shared electronically with the corresponding author.

Data from the case notes were analyzed thematically – a process that entailed reading through a first case note and documenting a list of tentative themes identified at ‘descriptive’ and ‘conceptual’ levels (Shallcross et al., 2019): straightforward descriptions of specific experiences were noted, in addition to more complex concepts that required deeper reflection and piecing together.

Themes were either confirmed or disconfirmed after reading subsequent case notes and finding that they either re-emerged or did not. New tentative themes were also added to the list as the reading of subsequent case notes ensued, and they were subjected to the same process of confirming/disconfirmation by comparing them to other case notes in the data set. The final list of themes was produced via multiple readings of all case notes to be sure nothing was overlooked or erroneously labeled as a theme without evidence of multiple tellings across counseling cases.

Five overarching themes emerged from the analysis, revolving around sexual violence, adverse childbirth outcomes, psychological trauma (of girls and their parents alike), parents’ need for support, and family support. These themes are unpacked in the sub-sections below.

Sexual violence

Sexual violence turned out to be the most prominent theme across the majority of the case notes, with many girls indicating that they had gotten pregnant as a result of rape. This is reflective of the larger, quantitative survey from which from which the case notes emerged. The endline survey results showed that, out of the 48 ever pregnant girls within the sample of 12 to 16-year-olds, over a third (35%) reported that they had gotten pregnant as a result of rape or coercion (MoE & Population Council, 2019). Indeed, only 5 out of the 20 pregnant/parenting girls who received home-based counseling during data collection became pregnant as a result of consensual sex.

Oftentimes, sexual violence occurred in the context of girls’ ‘boyfriend-girlfriend’ relationships, which supports findings from an earlier study in the same sites which indicated that about 90% of teenage mothers reported getting pregnant by their boyfriends, with a considerable proportion of these boyfriends (37%) being their fellow students (Undie et al., 2015a). Other perpetrators that emerged from the case notes included relatives, friends, and strangers.

Pregnant girls also struggled with disclosure, due to the notion that their experience of rape was their fault, and that support and sympathy would not be readily available.

I was interviewing this girl, and when we got to the section on sexual experiences, she started crying. I stopped the interview and asked her if she would like to talk to me as I assured her of total confidentiality. She trusted me and she opened up that she is pregnant, and she has not told anyone, including her mom. She is fearing her mom will kick her out of the house and she has no idea what to do. She said her boyfriend, who is in [secondary school], forced her to have sex when she didn’t want to: “My boyfriend was escorting me one evening and he started ‘touching-touching’ me. I told him to stop, and he refused to. Before I knew it, he had pulled me in the bush and had sex with me. I tried to scream, but he covered my mouth. After he finished, he warned me never to tell anyone. I have not gotten my period for 3 months now, and when I went to the hospital, I was told I am pregnant. I’m so scared what my parents will say. 13-year-old girl

Her mother left her and her brothers behind under the care of their paternal step uncle, while their father travelled to Nairobi. Two days later, the said uncle raped her. She said she screamed and her … brother, who was then 12 years old, raised alarm and neighbors came to their rescue. She remembers how she bled profusely and was admitted to the hospital for two weeks. The uncle ran away and disappeared. He was being sought by police but could not be traced. A few days later, his body was found in the forest. He had hung himself. During burial, the family agreed the matter was to be kept a secret, while her step grandmother threatened she would kill them all for causing her son to commit suicide. She never told anyone about this story, not even her own mother. 15-year-old girl

The girl … didn’t want to continue with the interview. I stopped the interview and asked her if there was anything that she would like to share, and she mentioned that her uncle visited them and found her parents had gone for a burial and took advantage of her. The girl mentioned that if she tells her parents, they will blame her: ‘’Kindly don’t share this with them. This is the person I trusted most, but he betrayed me. He pulled me into the house, and I tried to scream, and he warned me that if I continued, he would kill me. He had sex with me and warned me never to tell anyone. This has made me feel so bad … I hate him and I don’t like seeing him or even his wife.” 13-year-old girl

Adverse childbirth outcomes

Adolescent mothers face higher risks of adverse birth outcomes than older mothers (WHO, 2020). This reality can place extra pressure on girls whose babies face health challenges, coupled with the stigma of being a young mother of school-going age, and the prevalent experience of rape-related pregnancy. Some teenage mothers returning to school (or trying to) are grappling with raising children with health issues, or with the loss of their children, for example. The case notes served as a reminder of the intersecting challenges faced by teenage mothers who do not come away with the expected birth outcome of a healthy child:

She is the second born in a family of 5 children. Her childhood development was hampered by delay in walking till age three. She started school at age six and but at some point she repeated primary 7 three times. During that period, she was raped by a stranger, and she conceived. She continued [going to school] until delivery. It was a pre-term baby delivered at six months. … Her baby is stunted in growth – seemingly has hydrocephalus. He is 1 year and six months old, but cannot walk. 16-year-old girl

She was referred by [a data collection team member] following the loss of her 3-day old infant (had breathing problems from birth). The interviewer reported to me that she was teary during their interview session … [Her] baby died after she was discharged from the hospital. 15-year-old girl

Psychological trauma

Girls

During their counseling sessions, pregnant/parenting girls showed evidence of psychological trauma as a result of their pregnancies (and other associated concerns), whether the latter were rape-related or not. All psychologists noted the deep traumatization of the girls concerned, with one specifying that, while the first line of counseling provided was important and helpful, many of the girls actually required long-term psychotherapy.

The sexual debut of many girls occurred in the context of sexual violence. Several girls found it challenging to disclose their horrifying experiences to anyone, and had not spoken about them until they were asked if they wanted to speak to someone during data collection for the wider study. Similar findings emerged from Kenya’s second Violence Against Children Survey (MLSP, 2019), which demonstrated that 43% of 13- to 17-year-old girls who experienced an incident of sexual violence in the past 12 months did not tell anyone about their experience.

The circumstances described above resulted in a wide range of psychological problems and mental health issues described by pregnant and parenting girls, including depression, fear, suicidal ideation, insomnia, reduced self-esteem, and hopelessness, as outlined below:

(The girl started crying). I gave her time and I asked her if she was ready to continue. This was after doing a bit of counselling and she was okay… She said, “[A boy I met on the road while running an errand] locked me up for two days and threatened that if I dare screamed, he would kill me. I didn’t know his parents had travelled and he knew he was all alone, and nobody would know what was happening. He had sex with me, which was the worst experience that I have ever had. I cried, but he was not ready to let me go. He forced me. After the second day, he let me go, but he warned me never to tell anyone. The experience was very scary, and I didn’t tell my mom or anyone. I thought she would beat me. I used to cry every day[.] … After one month, I noticed some changes and I started throwing up and getting sick. My mother took me to the hospital, and I was pregnant. This broke me into pieces, and I didn’t have a way forward. I wanted to commit suicide[.] 15-year-old girl

The girl was very innocent, and she hadn’t started her period yet. … She remembers this day when there was a function at his place [a family friend and peer]. “[E]veryone, including my family, attended. … It was a bit dark [when it was time to go home], and I was scared. He offered to escort me and since he was like a brother, I didn’t mind. … All of the sudden, he started removing my clothes and I had no idea what was going on. I told him to stop, but he refused. I got so confused and before I knew it, he started ‘doing bad manners to me’ [having sex with me]. I screamed and I cried, but he covered my mouth. Once he was done, he left me and warned me never to tell anyone. I was very scared, and I didn’t sleep for 2 weeks. I had nightmares. After a few months, I started seeing my stomach [growing] big. I had no idea what was happening.” Age not recorded

Her sleep is not smooth: “I see demons and sometimes wake up screaming loudly,” she said. 17-year-old girl

I then did a … [counseling] session with … [the girl] who was very traumatized and had threatened suicide. This was the most difficult session because, at the middle of the session, the girl broke down. She said her mom and siblings have not been talking to her and they have no idea what happened. “I was raped,’’ said the girl. She said nobody ever asked her [what happened]. I gave her time to calm down and later on she explained to me that her boyfriend, who was in [secondary school], forced her to have sex when she was on her way home from church. “He convinced me to stop by his house and he locked the door and raped me. I tried to scream, but he covered my mouth. I didn’t know I got pregnant until I missed my period. 15-year-old girl

This particular girl was forced to have sex by her boyfriend, and she got pregnant. She was very traumatized, and she feels useless. “I feel as if there is no need of living,” the girl said. She said … when she visited [her boyfriend] as she used to do, he pulled her into the bedroom and started to undress her. She tried to shout, but he covered her mouth. “I have never had sex before, and this left me pregnant.” 14-year-old girl

Parents

The case notes analysis also surfaced the psychological trauma confronted by the parents of pregnant and parenting girls – an issue that has received much less attention in the literature. This trauma manifested in the forms of sadness, despair, bitterness, and anger, for instance, and led some parents to act out against their pregnant/parenting daughters, including by being harsh (verbally and physically), belittling pregnant/parenting girls before their siblings, lashing out, and simply ignoring or ostracizing their daughters. This often led to situations of ‘ping-pong’ trauma within affected girls’ households, as such girls inadvertently inflicted trauma on their parents as a consequence of their pregnancy/parenthood status, while parents, in turn, unknowingly triggered further trauma in their daughters when they left their own trauma unattended to. The quotes below illustrate the complex psychological terrain navigated by parents of pregnant and parenting girls:

Her mom was so bitter after realizing she was pregnant that she didn’t say a word to her. … She told me she is a single mother, and her daughter has really disappointed her: “Can’t they see how I am struggling?’’ she said, as she broke into tears. She told me her [elder] daughter … also got pregnant in school, and she had to struggle with the baby and her. She thought her younger sister would have learnt from her [experience]. She said she doesn’t want to see her, or even find out the person responsible for the pregnancy: ‘’If she wants, let her leave.’’… After a long counseling [session], the mom was satisfied, and she was ready to support her daughter. She said talking about the issue had helped her and she feels better now.

I counseled [the pregnant girl] and I explained to her the importance of disclosing to her parents and asked her she if was ready to tell her mother herself. She agreed and she told her mom, who was very devastated. I had a deep counseling session with her mom, and she told her daughter she should have reported to her as soon as [the rape] happened. She would have helped by taking her to the hospital. She said she had no idea how she would break the news to the girl’s dad.

The father … would occasionally speak badly to her [making remarks] such as, “You! You’re still seated at home, baby-sitting, while your classmates are in school studying.” … I had a [counseling] session with [him], which was fruitful and productive. He admitted that indeed he was disappointed in his daughter, since she was the most quiet and humble of his children, and finding out that she became pregnant because a boy bought her mandazis [Kenyan doughnuts] worth 20 shillings was very disappointing, to say the least. He admitted that, in his anger, he had spoken harsh words to his daughter.

Parents’ need for support

A recurrent theme among parents of pregnant and parenting girls was their need for external support in talking to their daughters about sex and sexuality. After participating in the quantitative survey under the wider study, parents of pregnant/parenting girls commonly asked for someone to speak to their affected daughters about these issues, admitting their difficulty in doing so themselves.

This challenge plausibly stems from cultural prescriptions in some Kenyan sub-cultures, which hold that conversations about sex and sexuality contravene notions of ‘respect’ within parent-child relationships (Undie & Mak’anyengo, forthcoming 2022). Consequently, parent-child communication around these subjects is often only prompted by negatively-perceived events, including early pregnancy (Maina, Ushie, & Kabiru, 2020). The following narratives depict this communication challenge faced by parents of pregnant/parenting girls:

[O]ne of the Head Teachers who had attended [one of the project’s policy] dialogue meetings … had two teenage girls, and after interviewing the girl who was sampled in the study, he requested me to counsel his daughters: “You know, these things affect us as well. We are also parents, despite being leaders at school.” He said that this is one of the reasons he was advocating for girls to remain in school as long as they want (even if they are pregnant). He said some Head Teachers may never understand until this menace of teenage pregnancy strikes them. I had a very successful session with [his] two open girls, who said they had experienced a lot of challenges with their peers at school. … The parents came to thank me and told me this is what they need in the community: Someone to talk to the girls. The dad [Head Teacher] said it’s hard, at times, to talk about sex with their girls.

On finishing up the interview [with this household head/parent], she asked, “What can we do for these girls of ours who still get pregnant even after we to try meet their needs? … I [empathized with] her frustrations, while helping her identify her strengths as a parent [e.g., by] meeting her daughter’s needs, but at the same time, pointed out to her some of the gaps that most parents experience during parenting – like [in the area of] sex education/talks … which, she agreed, is always a tough topic.

A mother … requested the data collectors to help counsel her 13-year-old daughter who gave birth and went back to school, [along with] her eldest daughter, who was equally intelligent, but whom she feared would be influenced. This mother of six and widow feared that her young daughter might have not learned from her previous experience, and may be taken advantage of again, [even though her mother] was struggling to provide for them with her meager income (she sold roasted groundnuts for a living).

The fact that all parents who received counseling responded positively to this service (even when they had not requested for it, but were drawn into counseling by the proactive psychologists) is a further indication of the sheer need that parents have for support in order to properly support pregnant/parenting girls in turn.

Family support of girls

Despite the displeasure of most parents about their daughters’ early pregnancies, the vast majority expressed willingness to support their daughters’ return to school, or were already doing so. Parental support was demonstrated in other ways, as well, including by showing kindness and unconditional love toward their daughters, despite their disappointment, or by providing emotional support.

“I wanted to commit suicide, but my mom encouraged me and walked the entire journey with me. I would have been dead by now. Later on, I gave birth, and this was very traumatizing, and I felt the world had come to an end. I thank God for the support I got from my parents. And after a few months, I told them I wanted to go back to school. They were ready to take me back to school, and that is why I am in Class 8 now, waiting for the national exam results to be out, and I’m expecting good results.” She talked of how her parents are struggling financially to keep her in school. 15-year-old girl

She was not planning to tell her mother [about her pregnancy], but after helping her come into terms [with it] and understand the importance of disclosure, she explained to her mom [what happened]. She thought her mom, who is very [strict], would kick her out of her house, but her mom was so shocked and lost for words. But she promised to support her in going back to school, since she was a very intelligent girl. 14-year-old girl

At the end of the counselling session, which was very long, we involved the parents, who were very supportive, especially [in regard to] making sure she goes through school. 15-year-old-girl

Notably, grandmothers emerged several times as avid supporters of their pregnant/parenting granddaughters. Grandmothers’ homes appeared to be places of succor for affected girls. Anecdotal data from the wider study suggested that, for ‘shame-related’ reasons, girls were often sent to live with other relatives when they became pregnant, only returning after delivery. Nonetheless, grandmothers in particular emerged from the case notes analysis as relatives that offered a safe space and ‘guaranteed’ support for pregnant/parenting girls:

[After having a baby], she relocated to her maternal grandmother’s home, where she currently goes to school. 16-year-old girl

The mother was supportive and urged her to … be at peace. Thereafter, she was taken to grandmother’s place, where she delivered[.] 15-year-old girl

Her paternal grandmother loves her and her baby, so she will possibly take care of the baby while she will be at school. 16-year-old girl

Kenya has taken notable steps toward normalizing continued schooling for pregnant and parenting girls, demonstrating strong political will and leadership in the East African region, along with boldness and innovation. The findings from this Kenya-based study can only help in strengthening existing efforts to support pregnant and parenting girls, and in accomplishing Kenya’s ambitious ICPD25 commitment to end teenage pregnancy (NCPD, 2021). The achievement of these efforts and commitments will require attention toward the psychosocial support challenges of pregnant and parenting girls. Drawing on the voices of affected girls and their parents, this paper has outlined key areas in which such psychosocial support is needed.

The high magnitude of sexual violence among teenage girls in Kenya is better known now than ever before. The realities of girls in this study who experienced sexual violence mirrored those of their peers nationwide: Perpetrators were often the girls’ schoolmate boyfriends or peers, and pregnant/parenting survivors were reticent about disclosing their experience of violence. These findings draw our attention to the need to think about boys as part of the portrait of teenage pregnancy. Related to this is the critical need for sexuality and relationships education (which would include sensitization to certain concepts such as gender-based violence, consent, self-management, kindness, and relationship skills [UNESCO, 2018], for example) as a glaringly absent piece in the discourse and programming around teenage pregnancy in Kenya. Such education is clearly required right from the primary school level, which was the level of schooling of the vast majority of girls in this study. While the Kenyan government has demonstrated support for sexuality education, it has privileged abstinence-only approaches (Sidze et al., 2017), which, in addition to being incomprehensive, overlook the realities of sexual violence (and other grave, sexuality-related issues) occurring as early as the primary school level. The need for sexuality and relationships education is all the more important, given parents’ recurrent request in this study for external support in communicating with their children about sex and sexuality. Sexuality and relationships education efforts could, therefore, be designed to support parents in this regard, and to complement related, school-based endeavors.

Historically in Kenya, narratives of exclusion were prevalent when it came to pregnant/parenting girls and their continued education. Overtime, these have been replaced by an inclusion rhetoric, backed with action to support girls’ school re-entry. Both approaches have fixated on either excluding or including pregnant and parenting girls, without much consideration of the range and severity of mental health issues experienced by girls in these circumstances, and the need to attend to these to ensure an effective inclusion approach. The integration of mental health services into the education sector, and into maternal health services for adolescents is worthy of consideration.

The study’s findings demonstrate that mental health concerns are not the preserve of pregnant/parenting girls alone. Parents of girls who have experienced pregnancy often face psychological trauma of their own, which must be acknowledged and addressed, given the expectation in Kenya’s school re-entry policy guidelines (and emerging narratives around parental engagement in Kenya [Syomwene, 2022; Kimiri, 2021; KICD, 2019]) that parents would play a larger role in supporting their children’s education. Intersections between adolescent and parental trauma also require a response and further investigation in the context of teenage pregnancy, given evidence of their co-occurrence in this study. While this intersection could potentially have a cyclical effect, prolonging recover for both girls and their parents, it also holds potential for whole-family healing, if properly addressed. Although this emerged only once in the present study (in a case where a pregnant girl and her mother alike were physically abused by her father in response to her pregnancy), intersections between violence against girls and violence against women in the context of teenage pregnancy are also worth exploring further, given the likelihood that this is occurring much more than this study was able to capture.

It is also important to highlight existing family support for pregnant and parenting girls as a major theme that emerged in this study. Childcare is a major barrier to school re-entry among pregnant and parenting girls in Kenya (Undie et al., 2015a). Sustainable resolutions for this issue might entail integrating Early Childhood Education interventions into primary and secondary schools. In the meantime, parents, grandparents, and other relatives can serve as important childcare resources to ensure the re-entry and retention of pregnant and parenting girls.

ICPD International Conference on Population and Development

MoE Ministry of Education

Ethical approval and consent to participate

Ethical approval for the study (including consent processes for respondents’ participation) from which this paper’s data were derived was granted by the Kenyatta National Hospital-University of Nairobi Ethics and Research Committee in Nairobi, Kenya (Reference Number KNH/ERC/R/151), and from the New York-based Institutional Review Board of the Population Council (Protocol 843).

Consent for publication

Not applicable.

Availability of data and materials

The dataset analyzed during the current study is available from the corresponding author or reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

This study was made possible by funding from the Wellspring Philanthropic Fund.

Authors’ contributions

CU conceptualized the study, analyzed and interpreted the data, and drafted the manuscript. HB made substantial contributions to the acquisition and interpretation of the data. All authors read and approved the final manuscript.

Corresponding author

Chi-Chi Undie

[email protected]

Emerson RM, Fretz RI, Shaw LL. Writing ethnographic fieldnotes. Chicago: University of Chicago Press; 1995.
Gachoya A, Kirongo T, Kiiru F, Odwe G, Undie C. Re-opening in the time of COVID-19 in Kenya. Regional Education Learning Initiative. 2021. https://reliafrica.org/re-opening-in-the-time-of-covid-19-in-kenya/. Accessed May 31, 2022.
KICD (Kenya Institute of Curriculum Development). Competency based curriculum: Guidelines on parental empowerment and engagement. Nairobi: KICD; 2019.
Kimiri A. Parental engagement: The magic bullet that countered school dropouts. Regional Education Learning Initiative. 2021. https://reliafrica.org/parental-engagement-the-magic-bullet-that-countered-school-dropouts/. Accessed June 1, 2022.
KNBS (Kenya National Bureau of Statistics), ICF International. 2014 Kenya Demographic and Health Survey Key Findings. Rockville: KNBS and ICF International; 2015.
Kumar M, Huang K-Y, Othieno C, Wamalwa D, Madeghe B, Osok J, Kahonge SN, Nato J, McKay MM Adolescent pregnancy and challenges in Kenyan context: Perspectives from multiple community stakeholders. Global Soc Welf 2018;5(1): 11–27.
McLean et al., 2015: The patient-body relationship and the ‘lived experience’ of a facial burn injury: A phenomenological inquiry of early psychosocial adjustment Journal of Multidisciplinary Healthcare 2015;8: 377–387.
Maina BW, Ushie BA, Kabiru CW. Parent-child sexual and reproductive health communication among very young adolescents in Korogocho informal settlement in Nairobi, Kenya. Reprod Health. 2020;17(1):79.
Ministry of Education. 2020. "National guidelines for school re-entry in early learning and basic education." Nairobi: Ministry of Education, Republic of Kenya.
Ministry of Education & Population Council, 2019. School re-entry and retention policies in Kenya: Homa Bay County Head Teachers’ dialogue. [PowerPoint slides]. Ministry of Education and Population Council, Kenya. https://www.popcouncil.org/uploads/pdfs/2019RH_Baseline_Results_Phase_II.pdf.
MLSP (Ministry of Labour and Social Protection of Kenya, Department of Children’s Services). 2019. Violence against Children in Kenya: Findings from a National Survey, 2019. Nairobi, Kenya.
Muiruri, M. (2020). Kenyatta orders registration of all pregnant teens for natal care. Daily Nation. July 9, 2020.
NCPD (National Council for Population and Development). 2021. Draft action plan for addressing adolescent health and teenage pregnancy in Kenya. https://ncpd.go.ke/wp-content/uploads/2021/10/Draft-Action-Plan-for-Addressing-Adolescent-Health-and-Teenage-Pregnancy-in-Kenya.pdf.
Odwe, G. & Undie, C. (2021). Kenya tests the 4Ts to get girls back to school. Regional Education Learning Initiative. https://reliafrica.org/kenya-tests-the-4ts-to-get-girls-back-to-school/
Odwe, George, Chi-Chi Undie, Ann Gachoya, Truphena Kirongo, Fredrick Kiiru, and Jane Njogu. 2021. "Getting girls back to school in Kenya: The 4Ts (‘Trace, Track, Talk and reTurn’) Initiative implementation report." Nairobi: Population Council Kenya.
Oulo, B., Sidle, A.A., Kintzi, K., Mwangi, M., Akello, I. 2021. “Understanding the Barriers to Girls’ School Return: Girls’ Voices from the Frontline of the COVID-19 Pandemic in East Africa.” AMPLIFY COVID-19 Research Brief. Nairobi, Kenya.
Population Council, Regional Education Learning Initiative, & Mannion Daniels. (2021). Advancing Girls’ Education in Light of COVID-19 in East Africa: A Synthesis Report. Nairobi, Kenya: Population Council.
Sanjek R, ed., 1990, Fieldnotes: The makings of anthropology, Ithaca, Cornell University Press.
Sidze, E.M. (2019). Fresh insights into the lives of Kenya’s urban teen mothers. The Conversation
Sidze, E.M., Stillman, M., Keogh, S., Mulupi, S., Egesa, C.P., Leong, E., Mutua, M., Muga, W., Bankole, A., & Izugbara, C.O. 2017. From paper to practice: Sexuality education policies and their implementation in Kenya, New York: Guttmacher Institute, https://www.guttmacher.org/report/sexuality-education-kenya.
Syomwene, A. 2022. Parental involvement strategies and challenges in development of pupils’ literacy skills in the implementation of competency-based curriculum in early years education in Kenya. European Journal of Education and Pedagogy 3(2).
Undie, C. & Birungi, H. (2016). Are school principal ‘the bad guys’? Nuancing the narrative of the school re-entry policy implementation in Kenya. In (eds.) Auma Okwany and Rekha Wazir, Changing social norms to universalize girls’ education in East Africa: Lessons from a pilot project. Garant Publishers …
Undie, Chi-Chi, Harriet Birungi, George Odwe, and Francis Obare. 2015a. "Expanding access to secondary school education for teenage mothers in Kenya: A baseline study report," STEP UP Research Report. Nairobi: Population Council.
Undie, C., Birungi, H., Odwe, G., Obare, F. 2016. Homa Bay County school heads dialogue on Kenya’s school re-entry policy [PowerPoint slides]. Population Council, Kenya. https://www.popcouncil.org/uploads/pdfs/2020RH_Phase_I_Evaluation_Results_Kenya.pdf.
Undie, Chi-Chi, Ian MacKenzie, Harriet Birungi, Stephen Barongo, Diosiana Ahindukha, and Caleb Omondi. 2015b. "Education sector response to early and unintended pregnancy: A policy dialogue in Homa Bay County, Kenya," STEP UP Meeting Report. Nairobi: Population Council.
Undie, C. & Mak’anyengo, M. (forthcoming, 2022). ‘How can I tell my mom such a story? Don’t you think she will beat me to death?’: The socio-psychological context of sexual violence against children in Kenya. In S. Pachauri, R. Verma & K. Mittal (eds.) Transforming Unequal Gender Relations: Interrelated Perspectives on Challenges and Opportunities. [Location: Publisher].
UNESCO. 2018. International technical guidance on sexuality education: An evidence-informed approach. Paris, France: UNESCO.
Wainana, C.W., Sidze, E.M., Maina, B.W., Badillo-Amberg, I., Anyango, H.O., Kathoka, F., Khasowa, D., & Okoror, C.E.M. (2021). Psychosocial challenges and individual strategies for coping with mental stress among pregnant and postpartum adolescents in Nairobi informal settlements: A qualitative investigation. BMC Pregnancy and Childbirth 21(661).
World Health Organization (2020). Adolescent pregnancy: Key facts

No competing interests reported.

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Editorial decision: Major revision
06 Aug, 2022
Reviews received at journal
29 Jul, 2022
Reviewers agreed at journal
17 Jul, 2022
Reviewers invited by journal
18 Jun, 2022
Submission checks completed at journal
15 Jun, 2022
Editor assigned by journal
15 Jun, 2022
First submitted to journal
15 Jun, 2022

You are reading this latest preprint version

What to Expect When Girls are Expecting: Psychosocial Support Challenges and Opportunities in the Context and Aftermath of Teenage Pregnancy in Kenya

Status:

Version 2

Abstract

Plain English Summary

Background

Methods

Study Context

Ethical Considerations

Study Design and Sample

Data Collection and Analysis

Results

Sexual violence

Adverse childbirth outcomes

Psychological trauma

Girls

Parents

Parents’ need for support

Family support of girls

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 2